Provider Demographics
NPI:1902548902
Name:KELLER, JENNA MARIE
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:MARIE
Last Name:KELLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 DAWN MARIE LN
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:26710-7413
Mailing Address - Country:US
Mailing Address - Phone:304-788-5467
Mailing Address - Fax:304-788-6363
Practice Address - Street 1:51 DAWN MARIE LN
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WV
Practice Address - Zip Code:26710-7413
Practice Address - Country:US
Practice Address - Phone:304-788-5467
Practice Address - Fax:304-788-6363
Is Sole Proprietor?:No
Enumeration Date:2022-04-11
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV746283747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant